Many health insurance plans provide shared deductible and out-of-pocket limits that cover different types of benefits. For instance, a medical plan may share deductible and out-of-pocket expenses with the pharmacy and behavioral benefit plans. All of a member's medical, pharmacy and behavioral claims would be applied against one deductible plan limit and one out-of-pocket limit, instead of three separate sets of accumulators (i.e. deductible and out-of-pocket limits) for each benefit type.
Often different benefit types are administered by different claim adjudication systems, e.g., three separate systems to handle medical, pharmacy and behavioral claims. In order for these systems to properly apply a claim against a member's shared deductible and out-of-pocket limits, they each must be aware of the claims the other systems may have adjudicated for that member and the cost share amount applied to the shared accumulators. In a simple scenario, with three systems administering three different benefit types, medical, pharmacy and behavioral, there are numerous interfaces and exchanges that are needed. For instance, the medical system sends accumulator updates to the pharmacy and behavioral systems for medical claims; and pharmacy and behavioral systems need to send the medical system accumulator updates for a pharmacy claim or behavioral claim, respectively.
Further, for complex health care systems operating multiple medical systems, specialty benefit systems and external delegated entities, the number of interfaces needed to support the accumulator update process grows dramatically. Moreover, these interfaces are typically developed as “one-offs” where each interface has its own requirements and specifications. Consequently, there is a great deal of overlap and costs to maintaining and adding new interfaces. This problem is exacerbated by the advent of health care reform, whereby commercial medical plans need to include pharmacy, behavioral, physical health, dental and vision benefits as part of the core medical benefits with one set of shared accumulators.
Currently these interfaces are handled by each system receiving and sending file based updates to the other system. Typically these updates are grouped together based on a specified time interval and submitted in batches. This results in timing issues when a member submits multiple claims for different benefit types within a short duration of time. For instance, a member submits a $200 medical claim and a $100 pharmacy claim on the same day. Also assume the member's current out-of-pocket balance is $1800 and the maximum is set at $2000. The medical system processes the claim applying the $200 toward the out-of-pocket. The member's out-of-pocket maximum has now been reached but the medical system does not send the update to the pharmacy system until several days later as part of a batch process it runs. Meanwhile, the pharmacy system receives the $100 claim and also applies it toward the member's out-of-pocket since it is not aware of the $200 medical claim that was already processed. As a result the member has been charged an additional $100 when in fact the out-of-pocket maximum has already been reached. The member is dissatisfied and reports the issue, requiring the insurance company to investigate the matter, reconcile claims and correct the problem. Consequently, there is a need to provide a way to manage accumulator updates between multiple systems.